CLM-2026-016316
Desert Medical Group, Family Medicine. Service 2025-10-02 at office (POS 11). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Eric Watson
- Member ID
- UHC-38780-55
- Date of birth
- 2005-01-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-421853
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4807
- Coverage period
- 2025-05-01 to present
- Deductible
- $286.29 of $500.0057%
- Out-of-pocket maximum
- $259.09 of $2,000.0013%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6663550666
- Network
- In network
- Rendering NPI
- 5062209981
- Location
- Mesa, AZ · TIN 39-6249973
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | — | — | DeniedCO29 |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1 | $269.00 | $166.78 | — | — | DeniedCO29 |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 1,2 | $215.00 | $133.30 | — | — | DeniedCO29 |
| Totals | $507.00 | $314.34 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-482610
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020258 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-10-02: NAVIGATE-HMO (HMO), effective 2025-05-01. | |
| Timely filing | Fail | CO29 | Received 177 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Medical Group (6663550666). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Medical Group2025-10-02 10:29
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-03-28 01:36
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 177 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004053 | 2026-02-10 | Riverside Regional Medical Center | $257.00 | Needs review |
| CLM-2026-014892 | 2026-03-05 | Canyon Internal Medicine Associates | $165.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.